ATI RN
Critical Care Nursing Questions Questions
Question 1 of 5
The family of a critically ill patient has asked to discuss organ donation with the patient�s nurse. When preparing to answer the family�s questions, th e nurse understands which concern(s) most often influence a family�s decision to donate? (Select all that apply.)
Correct Answer: A
Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate. Incorrect Answers: B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality. C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation. D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.
Question 2 of 5
The nurse is caring for a critically ill patient with a very concerned family. Given that the family is under high stress, what nursing intervention will best ameliorate their stress while preserving independence?
Correct Answer: A
Rationale: The correct answer is A: Encourage the family to participate in patient care tasks. This intervention helps to alleviate stress by involving the family in care, promoting a sense of control and empowerment. It also fosters a collaborative relationship between the family and healthcare team. The other choices are incorrect because B only focuses on asking questions but doesn't actively involve the family in care. C may add pressure on the selected representative and exclude others. D limits family involvement and may increase stress by restricting visitation.
Question 3 of 5
Following insertion of a pulmonary artery catheter (PAC),a bthirbe. cpohmy/tessitc ian orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO ). Which action by the nurse best ensures the obtained value is accurate?
Correct Answer: B
Rationale: The correct answer is B because calibrating the system with central venous and arterial blood samples ensures accuracy of the mixed venous oxygen saturation (SvO2) measurement. This calibration allows for comparison of the values obtained from both sources to confirm the accuracy of the measurement. Choice A is incorrect because zero referencing the transducer at the level of the phlebostatic axis does not directly address the accuracy of the SvO2 measurement. Choice C is incorrect because ensuring patency of the catheter using normal saline pressurized at 300 mm Hg does not directly impact the accuracy of the SvO2 measurement. Choice D is incorrect because using noncompliant pressure tubing does not ensure the accuracy of the SvO2 measurement. The length of the tubing and the presence of stopcocks are not directly related to obtaining an accurate SvO2 value.
Question 4 of 5
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation. A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade. C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level. D: CAM-ICU assesses delirium, not neuromuscular blockade.
Question 5 of 5
A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient�s family member, is most appropriate?
Correct Answer: B
Rationale: The correct answer is B because an increase in heart rate and respiratory rate can be a normal response before body system functions decrease in a hospice patient. This is known as a compensatory mechanism as the body tries to maintain oxygenation. Choice A is incorrect because symptoms may not always continue to increase until death. Choice C is incorrect as it implies a reflex response, which may not be the case. Choice D is incorrect as an improvement in the patient's condition is unlikely in a hospice setting.
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